Metacognitive antecedents to states of mental ill-health: Drops in confidence precede symptoms of OCD

Mental health symptoms, like those in obsessive-compulsive disorder (OCD), show pronounced fluctuations over time. However, little is known about the underlying factors driving these fluctuations. Whilst theoretical accounts propose that cognitive processes drive symptom variability, cross-sectional work is unable to effectively probe these mechanisms. Based on prevailing notions of doubt and underconfidence being cognitive hallmarks of OCD, we investigated whether metacognitive processes correspond to OCD symptoms. We employed a novel smartphone-based momentary assessment design wherein participants with OCD (N = 137) logged instances of experiencing OCD symptoms across 2-weeks. Participants also completed daily scheduled assessments, and played a perceptual metacognitive task every two days. Our results showcase the validity of our novel approach and, importantly, reveal that metacognition drives OCD symptoms. Concretely, we found directional effects whereby reductions in both self-confidence and task-based metacognition preceded occurrences of OCD symptom logs, but not vice versa. Thus, our novel micro-longitudinal study design provides compelling evidence for cognitive distortions (both self-reported and task-based) preceding symptom escalations, signifying the potential for designing novel, just-in-time interventions.